Provider Demographics
NPI:1649381153
Name:KIM, SOON (MD)
Entity Type:Individual
Prefix:MRS
First Name:SOON
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 VIRGINIA RANCH RD
Mailing Address - Street 2:
Mailing Address - City:GARDNERVILLE
Mailing Address - State:NV
Mailing Address - Zip Code:89410-5794
Mailing Address - Country:US
Mailing Address - Phone:775-783-3020
Mailing Address - Fax:775-783-3021
Practice Address - Street 1:1516 VIRGINIA RANCH RD
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410-5794
Practice Address - Country:US
Practice Address - Phone:775-783-3020
Practice Address - Fax:775-783-3021
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV10696208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100502384Medicaid
VH29001601Medicare ID - Type Unspecified
NV100502384Medicaid
NVH60385Medicare UPIN
NVGJ523ZMedicare PIN